Significant Medication Error: Missed Anti-Seizure Medication Doses
Penalty
Summary
A resident with diagnoses including epilepsy, dementia, and headaches had a physician's order for Lamictal, an anti-seizure medication, to be administered twice daily. Over several days, five doses of Lamictal were missed due to the medication not being available. Multiple LPNs involved in the resident's care did not administer the medication as ordered, signed the Medication Administration Record as if it had been given, and failed to notify the physician or nursing supervisor about the missed doses. The pharmacy delivered only a partial supply of Lamictal due to concerns about drug interactions, but this information was not effectively communicated to the clinical team responsible for the resident's care. As a result of the missed doses, the resident experienced a breakthrough seizure and required transfer to the hospital. Documentation and interviews confirmed that the facility's policy required all medication administration issues to be reported to supervisory staff before the end of the shift, but this was not done. The facility's investigation did not address all missed doses, and the physician was not notified of the medication errors at the time they occurred.